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Flashcards in pulmonary inf./TB/sarcoidosis Deck (87):
1

questions to ask

sick contacts
travel hx

2

testing to do

CXR
sputum sample (40% can't)
-may need bronchoscopy

3

sodium levels may be

low

4

CAP org

Strep pneumo

5

cough mechanism prevents

URI from becoming LRTI

6

S. pneumo presentation

fever, hypothermia, tachypnea, cough +/- sputum (typically), dyspnea, chills/rigors/sweats
-ha, lack of appetite
-clammy, bluish skin
-N/V, joint pain
-fatigue
-inspiratory crackles, bronchial breath sounds
-may have hemoptysis
(non-hosp. pts, not chemo pt)

7

S. pneumo CXR

-+ CXR w/ infiltrate or consolidation

8

S. pneumo compensatory mechs

-low BP
-inc. HR

9

dx testing necessary?

not always; empirically tx for S.pneumo

10

S.pneumo tx

augmentin, levoquin, PCN, clindamycin

11

other dx

Cx, Gs, urine antigen testing

12

other orgs

Legionella pneumophilia
Group A, C, G strep
Staph aureus (inc. CA-MRSA)

13

complication with S. aureus (CA-MRSA)

fall months, get influenza-->secondary bac. pneumo

14

consider HIV testing

hypoxemic, bacteremic, young, otherwise sev. pts

15

HIV+ pts w/ CD4 count >200 more likely

to have CAP vs. OI

16

flu season

(sept-march)

17

if flu pt. 5 days oral Tamiflu again has high fevers, purulent sputum

S. aureus

18

S. aureus tx

vancomycin, zyvox (linezolid)$, PCN, augmentin

19

MRSA

bactrin, clindamycin, doxycyclin

20

-fever 101.5
-ha, chills, body ache, malaise
-"foggy"
-hyponatremic (121)
-WBC count low (4.2K)
-heating/cooling repair, produce section, etc

Legionella pneumonia
"Legionnaire's disease"

21

fogginess, altered may be due to

hyponatremia

22

Legionella on sputum Cx

very rarely
do urine antigen

23

Legionella symps begin

2-14 days post-exposure

24

Leg.: transmitted?

cannot be transmitted person-person

25

Leg tx 1st line

macrolide(clarithromycin, azithromycin)
doxycycline

26

Leg tx rec. abx, comorb.

resp. FQs
macrolide + B lactam (cefuroxime, amoxicillin, augmentin)

27

inpt. management

resp. FQ: moxifloxacin, levofloxacin, IV moxifloxacin, levaquin*

macrolide + beta lactam: azithromycin + ceftriaxone*

28

inpt ICU management

azithromycin or resp. FQ + antipneumococcal B lactam (cef, amp)

29

inpt. ICU tx for pts allergic to B lactams

FQ + aztreonam, tigecycline

30

inpt. ICU tx for high risk pseudomonas

piperacillin-tazobactam, cefepime, carbapenem, ciprofloxacine or levofloxacin
-poss. B lactam + aminoglycoside (gentamicin, tobramycin, amikacin)* rarely used

31

inpt. ICU tx for high MRSA risk

influenza, DM, HAP
(make sure covers pseudomonas and MRSA)
add vancomycin or linezolid

32

old, bed bound, nursing home: cause of pneumonia?

aspiration on own secretions
-don't cough

33

HCAP orgs

pseudomonas, MRSA

34

HCAP risks

-Antibiotic therapy in the past 90 days
-Acute hospital stay for at least 2 days in the past 90 days
-Residence in an extended care facility or recent prolonged rehab stay
-Need for infusion therapy (chemotherapy) or hemodialysis
-Home wound care
-Family member with infections involving multidrug resistant organisms
-Immunosuppressed patient

35

HAP develops

>48 hrs AFTER admission to hospital

36

VAP occurs in

a mech. vent. pt >48 hrs after intubation

37

what to do with intubation pts

-keep head of bed 30 degrees
-do mouth care (suction)
CULTURE!

38

HAP orgs

-S. aureus (MRSA)
-S. pneumo (DR)
-G- orgs
-ESBL prod. orgs (E. coli, Kleb, enterobacter)
-resistant to PCN, cephalosporins, use carbapenems
-CRE prod. orgs in enterobacter family: move to aminoglycosides (tigasil, tobramycin, etc)
-acinetobacter spp. (chron. ventilated, trachs): unasyn, tigacil (otherwise resist.)

39

HAP empiric tx

S. aureus/MRSA/pseudomonas coverage
-antipseudomonals (cefepime, ceftazidime, imipenem, meropenem, piperacillin-tazobactam, aztreonam)
-2nd antipseudomonal (Levofloxacin, Cipro, aminoglycoside)
-MRSA coverage (Vancomycin, Linezolid, also tigacil, cefteraline?)
-known ESBL carrier? (carbapenem)* right away!*

40

aminoglycoside

gentamicin
tobramycin
amikacin

(can give inhaled gentamicin!)

41

15 lb weight loss,
101 F 3 weeks
gen. malaise
coughing up thick green phlegm, foul smell
etOH, bad teeth

aspirated inf. sputum-->purulence in lungs-->cough up from bronchus
CXR: obvious lung abscess
-weight loss from anaerobic process

42

w/ lung abscess pt.

more...
may need to decorticate
(keep malignancy in ddx)

43

lung abscess pt. dx

probable anaerobic pneumonia w. lung abscess

44

probable anaerobic pneumonia w. lung abscess risks

aspiration risk : etOH, nursing home
-indolent symps w/ fever, weight loss
MORE

45

probable anaerobic pneumonia w. lung abscess tx

clindamycin
amoxicillin-clavulanate (augmentin (for anaerobes))
amoxicillin (not usually)
moxifloxacin (anaer. cov)

IV zosyn, IV carbapenems, IV clindamycin (for hosp. pts)

46

pulm. infiltrates in immuncomp pts

consider opportunistic orgs, viruses, protozoa, fungi
-

47

pulm infilt. in HIV pt w/. high CD4 >200 more likely to be

Strep pneumo vs. pneumocystis jiroveci or other OI

48

fungal etiology of pulm. infiltrates

aspergillus, histplasmosis, blastomycosis, coccidiodomycosis

49

reality with aspergillus

infects people who are SEVERELY immune compromised (not everyday ppl to avoid rent due to mold)
-pts will dev. fungal ball (not nec. causes sickness)
-causes UR allergy sympts (chronic dry cough, irritation)

50

coccidiodomycosis

valley fever

51

histplasmosis, blastomycosis

may be in immunocompetent ppl

52

viral etiologies of pulm. infiltrates

HSV, CMV pneumonia

53

other causes of pulm. infilt.

atypical mycobacterial infections
(pts with sticky airways, high Ig levels, floppy airways)
(40-80 yo tiny women)
no good tx (Tb drugs)

54

TB stats

In 2013 a total of 9,588 new TB cases were reported in the US
Incidence of 3.0 cases per 100,000 people
Decrease from incidence of 4.2% in 2012

Incidence among foreign-born is 13x greater
64.6% of all TB cases

Half of all cases of TB in 2013 occurred in California, Texas, New York, and Florida
4,917 total cases

86 total cases of MDR TB were identified in 2012

55

TB greatest country

MEXICO

56

+ tuberculin skin test

induration*
>15 mm in gen pop
>10 mm in HC workers, inc. risk
>5 mm in HIV+

57

TB blood testing

INterferon Gamma Release Assay (IGRA)
-QuantiFERON TB gold in-tube test (vs. T-spot TB test?)
*reduces tester error, can be used on BCG vaccinated pts

58

IGRA advantages

Requires a single patient visit to draw a blood sample.
Results can be available within 24 hours.
Does not boost responses measured by subsequent tests, which can happen with tuberculin skin tests (TST).
Is not subject to reader bias that can occur with TST.
**Is not affected by prior BCG vaccination.**

59

IGRA disadvantages

Blood samples must be processed within ~24 hours after collection while white blood cells are still viable.
There is limited data on the use of QFT-GIT in children younger than 17 years of age, among persons recently exposed to M. tuberculosis, and in immunocompromised patients.
Errors in collecting or transporting blood specimens or in running and interpreting the assay can decrease the accuracy and potentially lead to indeterminate results.
False positive results can occur with Mycobacterium szulgai, Mycobacterium kansasii, and Mycobacterium marinum.

60

if skin is - and quantiferon is +

it is POSITIVE
get CXR

61

if skin is + and quantiferon is -

interminate, consider factors (case by case)
get CXR

62

if pt. are on anti-inflammatory tx (anti-TNF)

MORE
drop chances of getting TB down to general population

63

TB seen where in lungs

top, oxygen rich, aerated

64

+ CXR

get 3 sputum samples, bronchoscopy if unable

65

if active TB

public health for MDRTB therapy

66

if 3 sputum samples neg

scarring on CXR

67

once latent TB established

discontinue tx

68

who should be tx?

everyone, esp. immuncomps, HIV+, those about to start immunosuppressive meds

69

what are risks if no LTBI tx taken?

lifetim
MORE

70

LTBI tx (6-9 mos)

isoniazid, rifampin
+follow liver function

71

this med does not play well with other

rifampin (for young ppl, not on many other meds) (used back up for BC) (fine for etOH)

72

active TB tx

RIPE: rifampin, isoniazid, pyrazinamide, ethambutol (streptomycin) *core*

73

active TB always send..

susceptibility Cx

74

1st 2 mos...
then 4 mos...

all 4 drugs
isoniazid, rifampin

75

never tx active TB with

single agent

76

isolate active causes?

no longer infectious after 2 wks tx

77

MDR-TB

resist. to INH and RIF

78

XDR-TB

less common INF, RIF, others, FQ

79

INH resistance

&&

80

Rifampin resistance

***

81

INH + Rifampin resistance

III

82

XDR-TB tx

admin 4-6 drugs in combo (*SUSCEPTIBLE*) : mult. 2nd line drugs, should include all avail. 1st line drugs
-newer agents, trial agents
-18-24 mos (2 yrs!)

83

sarcoidosis CXR

bilat perihilar finding, may have parenchymal involvement

84

biopsy of hilar nodes (sarcoidosis)

noncaseating granulomas
(excl. lymphoma)

85

serum ACE in sarcoid.

elevated in 40-80% pts

86

sarcoid. multisyst. presentation

skin, eye, joint involvement

87

sarcoid. tx

oral prednisone (mos-yrs)